Stereotactic radiosurgery for the treatment of recurrent high-grade gliomas: long-term follow-up

High-grade gliomas (HGG) are the most frequent primary central nervous system tumors; treatment of HCGs includes surgery and post-operative conformal radiotherapy associated with temozolomide (TMZ or procarbazine/lomustine/vincristine [PCV], specifically in patients with anaplastic oligodendrogliomas or anaplastic oligoastrocytomas). However, recurrence is common. Re-irradiation has been utilized in this setting for years and remains a feasible option, although there is always a concern regarding toxicity. Modern high-precision conformal techniques, including stereotactic radiosurgery (SRS), could improve the therapeutic ratio by delivering high biologically equivalent doses while reducing high-dose radiotherapy (RT) to normal brain tissue. In this paper, we present the results obtained after prolonged follow-up in patients who underwent SRS as a treatment for recurrent high-grade gliomas at San Francisco Hospital in Madrid, Spain

ESTRO IORT Task Force/ACROP recommendations for intraoperative radiation therapy in borderline-resected pancreatic cancer

Radiation therapy (RT) is a valuable component of multimodal treatment for localized pancreatic cancer. Intraoperative radiation therapy (IORT) is a very precise RT modality to intensify the irradiation effect for cancer involving upper abdominal structures and organs, generally delivered with electrons (IOERT). Unresectable, borderline and resectable disease categories benefit from dose-escalated chemoradiation strategies in the context of active systemic therapy and potential radical surgery. Prolonged preoperative treatment may act as a filter for selecting patients with occult resistant metastatic disease. Encouraging survival rates have been documented in patients treated with preoperative chemoradiation followed by radical surgery and IOERT (>20 months median survival, >35% survival at 3 years). Intensive preoperative treatment, including induction chemotherapy followed by chemoradiation and an IOERT boost, appears to prolong long-term survival within the subset of patients who remain relapse-free for>2 years (>30 months median survival; >40% survival at 3 years). Improvement of local control through higher RT doses has an impact on the survival of patients with a lower tendency towards disease spread. IOERT is a well-accepted approach in the clinical scenario (maturity and reproducibility of results), and extremely accurate in terms of dose-deposition characteristics and normal tissue sparing. The technique can be adapted to systemic therapy and surgical progress. International guidelines (National Comprehensive Cancer Network or NCCN guidelines) currently recommend use of IOERT in cases of close surgical margins and residual disease. We hereby report the ESTRO/ACROP recommendations for performing IOERT in borderline-resectable pancreatic cancer

Intraoperative radiotherapy in the multidisciplinary treatment of bone sarcomas in children and adolescents

From September 1984 to December 1989, 38 patients of pediatric age with localized bone sarcomas received intraoperative radiotherapy (IORT) as part of a multidisciplinary treatment program. The age ranged from 6 to 21 years. The tumor histologies were 22 osteosarcomas and 16 Ewing's sarcomas. Thirty-four had initial primary disease (90%) and 4 were treated for local recurrence (10%). IORT was used on 32 untreated patients and in 6 previously treated with external beam radiotherapy (EBR). The IORT field included the surgically exposed tumor bed area. Single radiation doses ranging from 10 to 20 Gy were delivered, using 6-20 MeV electron beams. The median follow-up time for the entire group is 25 months (2-65+ months). The projected 5-year disease-free and overall survival rates are 65% and 69%, respectively. One patient developed a local recurrence in each histological group: one chondroblastic osteosarcoma and one cervical Ewing's sarcoma. Six patients died from metastatic progression: 3 initially recurrent tumors and three primary disease cases. Severe neuropathy and soft tissue necrosis were seen in some patients as IORT related complications. IORT is a feasible technique to be integrated in multidisciplinary programs that may promote local control in pediatric and adolescent patients with bone sarcomas. Peripheral nerves are dose-limiting tissue structures for IORT

Cirugía derivativa más radioterapia intraoperatoria y externa en el carcinoma de páncreas localizado e irresecable

Presentamos una serie de 25 casos de carcinomas de páncreas localmente avanzados e irresecables, sin metástasis a distancia, tratados con cirugía derivativa, radioterapia intraoperatoria e irradiación externa: 18 tumores de cabeza (16 con ictericia obstructiva) y 7 de cuerpo. Se realizó derivación biliar en 18 y gastroyeyunostomía en 19. La mortalidad operatoria fue nula, con una morbilidad del 16%. A largo plazo se produjeron 3 hemorragias digestivas, 2 ictericias obstructivas, una colangitis y una obstrucción intestinal. Se obtuvo un 72% de control local de la enfermedad y todos los fallecidos por progresión tumoral desarrollaron metástasis hepáticas y/o peritoneales. Presentaban dolor pancreático 22 pacientes y 20 experimentaron remisión del mismo en una a 2 semanas. La analgesia fue definitiva en 12 y reapareció el dolor tardíamente en ocho. La supervivencia media fue de 9 meses (rango 4-24). La revisión de la literatura pone de manifiesto la indicación de la radioterapia externa tanto en el carcinoma de páncreas irresecable y no metastásico como en los resecados. La asociación de radioterapia intraoperatoria tiene, así mismo, un papel importante en cuanto a supervivencia, paliación del dolor y de la progresión local. El 5-fluorouracilo asociado al tratamiento radioterápico prolonga significativamente la supervivencia con una morbilidad razonable

Radioterapia en cáncer de recto localmente avanzado: situación actual y desarrollo terapéutico

La radioterapia es uno de los elementos integrantes del tratamiento radical del cáncer de recto localmente avanzado. La radioterapia preoperatoria y la radioterapia postoperatoria en combinación con quimioterapia han demostrado aumento del control local y la supervivencia. La tendencia actual es el uso de quimioirradiación preoperatoria por su mejor tolerancia y porque a los beneficios en control local y supervivencia se le podrían añadir los de mayor tasa de respuesta (downstaging) y un aumento de cirugía preservadora del esfínter anal. El desarrollo terapéutico en cáncer de recto localmente avanzado se sitúa en conseguir una mayor intensificación terapéutica sobre el tumor y las regiones de riesgo de recidiva sin aumentar la toxicidad sobre los tejidos sanos: esquemas de radioterapia con fraccionamientos modificados, radioterapia intraoperatoria, radioterapia con intensidad modulada de dosis, nuevos agentes quimioterápicos en combinación con radioterapia. En el presente artículo se revisan los datos más relevantes de esta modalidad terapéutica.Radiotherapy is one of the integral elements of the radical treatment of locally advanced rectal cancer. Combined chemotherapy and postoperative radiotherapy or preoperative radiotherapy has demonstrated an increase in local control and survival. The present trend is the use of preoperative chemoradiotherapy: this scheme seems to have a better tolerance and downstaging with an increase in sphincter-preserving surgery rates. Current therapeutic development in locally advanced rectal cancer focuses on obtaining a greater therapeutic ratio: with modified fractionation, intraoperative radiation therapy, intensity modulated radiation therapy, new chemoradiation regimens. The present work reviews the state of the art and the most significant advances in radiation in rectal cancer

ESTRO/ACROP IORT recommendations for intraoperative radiation therapy in primary locally advanced rectal cancer

Summary: Carcinoma of the rectum is a heterogeneous disease. The clinical spectrum identifies a subset of patients with locally advanced tumours that are close to or involve adjoining structures, such as the sacrum, pelvic sidewalls, prostate or bladder. Within this group of patients categorized as ‘‘locally advanced”, there is also variability in the extent of disease with no uniform definition of resectability. A practice-oriented definition of a locally advanced tumour is a tumour that cannot be resected without leaving microscopic or gross residual disease at the resection site. Since these patients do poorly with surgery alone, irradiation and chemotherapy have been added to improve the outcome. Intraoperative irradiation (IORT) is a component of local treatment intensification with favourable results in this subgroup of patients. International guidelines (National Comprehensive Cancer Network (NCCN) guidelines) currently recommend the use of IORT for rectal cancer resectable with very close or positive margins, especially for T4 and recurrent cancers. We report the ESTRO-ACROP (European Society for Radiotherapy and Oncology - Advisory Committee on Radiation Oncology Practice) recommendations for performing IORT in primary locally advanced rectal cancer

Intraoperative radiotherapy electron boost followed by moderate doses of external beam radiotherapy in resected soft-tissue sarcoma of the extremities

To analyze the patterns of failure and the toxicity profile of intraoperative electron beam radiotherapy (IOERT) after resection of soft tissue sarcomas of the extremities (STS). PATIENTS AND METHODS: Forty-five patients with extremity STS were treated with IOERT and moderate-dose postoperative radiotherapy (45-50 Gy). Twenty-six patients were treated for primary disease (PD) and 19 patients for an isolated recurrence (ILR). Tumor size was >5 cm (maximum diameter) in 36 patients (80%), and high-grade histology in PD patients was present in 14 patients (54%). In nine patients, IOERT was used alone, due to previous irradiation or patient refusal. Chemotherapy (neoadjuvant and/or adjuvant) was mainly given to high-grade tumors. RESULTS: Nine patients relapsed in the extremity (20%), and 12 patients in distant sites (28%). Actuarial local control at 5 years was 88% for patients with negative/close margins and 57% for patients presenting positive margins (P=0.04). Five patients (11%) developed neuropathy associated with the treatment. Extremity preservation was achieved in 40 patients (88%). With a median follow-up of 93 months (range: 27-143 months) for the patients at risk, 25 patients remain alive (a 7-year actuarial survival rate of 75% for PD and 47% for ILR; P=0.01). CONCLUSIONS: IOERT combined with moderate doses of external beam irradiation yields high local control and extremity preservation rates in resected extremity STS. Peripheral nerves in the IOERT field are dose-limiting structures requiring a dose compromise in the IOERT component to avoid severe neurological damage

Intraoperative and external radiotherapy in resected gastric cancer: updated report of a phase II trial

From September 1984 to August 1991, 48 evaluable patients with resected gastric cancer and apparent disease confined to locoregional area were treated with intraoperative electron beam boost to the celiac axis and peripancreatic nodal areas (15 Gy) and external irradiation (40 to 46 Gy in 4 to 5 weeks) including the gastric bed and upper abdominal nodal draining regions. At the time of evaluation for IORT, the disease was primary in 38 cases, recurrent but resectable in four (anastomosis), and unresectable in four (nodal). Post operative complications were reversible. Acute tolerance to the complete treatment program was acceptable. Late complications included life-threatening events: Six episodes of gastro intestinal bleeding (three of them had an arteriographic documentation of arterioenteric fistula) and nine with severe enteritis (five required reoperation). Other long-term treatment related complications were six cases of vertebral collapse. The median follow-up time for the entire group is 22 months. Locoregional recurrence/persistence of disease has been identified in five patients (three with residual and/or recurrent postsurgical tumor). Systemic tumor progression has been detected in 15 patients (11 in intra-abdominal sites). Overall actuarial survival for patients with positive or negative serosal involvement was 33% versus 56%. It is concluded that the treatment program described is able to induce a high locoregional tumor control rate (100%) when used strictly in an adjuvant setting and might control long term, a small portion of patients not amenable for curative surgery (2 out of 8 patients with confirmed residual post-surgical disease). Gastrointestinal bleeding and enteritis are findings that indicate treatment intensity at the upper limits of tissue tolerance. Assessment of long term tolerance of pancreatic parenchyma and large blood vessels (tissues included in the IRORT field) are pending for longer follow-up and the appropriate selective studies